News&Views

July 30, 2006

No Performance Anxiety

Filed under: — mlazoff

“In the United States, pay for performance is an idea whose time has come…”  writes health policy and management expert Arnold Epstein, MD, in an editorial published in this week’s NEJM: Paying for Performance in the United States and Abroad. Dr. Epstein describes several of the “operational building blocks for a national program of pay for performance” already in place. “With this kind of momentum building, it is very likely that Congress will pass legislation phasing in pay for performance by the CMS for physicians, hospitals, health plans, and possibly other providers. Although it would be premature to predict what the details of such a program would be, certain key features that will greatly affect practicing physicians are virtually assured…” He provides three: the public reporting of quality of care; the impact on specialists as well as general practitioners; and how “eventually measures of efficiency—how well physicians constrain costs while maintaining quality—will almost certainly become an important component of the targeted indexes….” In the final paragraph, Dr Epstein cautions that “Americans have long viewed themselves as being on the cutting edge, especially in comparison with their British and western European cousins. Yet the British are clearly ahead of us in the adoption of financial incentives for improving the quality of care. We would do well to learn from their experience.” 

Several lessons drawn from the experience of our colleagues across the pond are spelled out in the Discussion section of a Special Article published in the same NEJM issue, Pay-for-Performance Programs in Family Practices in the United Kingdom. “First, the U.K. program was costly and was funded with substantial additional monies rather than by restructuring existing payment systems. In addition to the payments for achieving quality targets, there were further costs, to both the practitioners and the government, of developing and implementing the information-technology systems required to monitor the program. Budget-neutral programs would face greater resistance from family practitioners. Second, a clear baseline is needed to avoid paying for improvements that have already occurred. Third, geographically staggered introduction would enable policymakers to better estimate the quality effects of the program. Fourth, introducing pay-for-performance incrementally reduces risks for providers and payers. Fifth, payers should allow for the possibility of higher-than-expected achievement. Sixth, the risk of inappropriate treatment can be decreased with the use of mechanisms such as exception reporting, but monitoring is required to prevent abuse.”

Kudos to NEJM for making both articles freely available; let’s hope the Letters to the Editor in response to these important, controversial articles will likewise be made available to all.



July 28, 2006

Top 10 HIT list, eh?

Filed under: — mlazoff

Canada Health Infoway, an independent nonprofit organization that describes its mission as, “to foster and accelerate the development and adoption of electronic health information systems with compatible standards and communications technologies on a pan-Canadian basis…” studied the contributing factors behind the high rate of information technology adoption and use among GPs in 10 countries: England, Scotland, Denmark, Sweden, Norway, the Netherlands, Austria, Germany, New Zealand and Australia. According to a summary of the 2005 report released earlier this month, more than 95% of GPs in each of these countries except Germany use computers for at least one patient care activity, most commonly for receiving laboratory results online. “Findings were based on data collected from scientific studies; reports from governments, professional associations and the Organization of Economic Cooperation and Development (OECD); and interviews with physicians and government representatives.” See the excellent Adoption of IT by GP/FMS: A Ten Country Comparison for PDF reports on each individual country; just above is a link to a slide show by the Canada Medicial Association on a Physician Technology Usage and Attitudes Survey conducted on almost 2000 Canadian physicians in 2005. By comparison to these other countries, only 20% of Canadian GPs use computers in patient care, including electronic medical records (EMRs). “[Canadian] [p]hysicians say that improving quality and efficiency of their practices and saving time are the top two reasons why they would adopt an EMR in their practices. These are followed by many factors seen as important in other countries, such as the need for compensation and proper support.” Given the importance of quality care to Canadian physicians, it is fortuitous that the latest news item on Infoway’s Web site is International Experts Show Electronic Health Records Improve Healthcare.



High grades for low-tech device

Filed under: — mlazoff

Braille writerAccording to a Johns Hopkins press release, four Whiting School of Engineering undergraduates created a low-cost portable Braille writing tool as a class project. The mechanical handheld device produces up to six indentations at once within each Braille slate cell—unlike a stylus, which can only make one indentation at a time. Acccording to the press release, “When the students began the project, they decided that a six-pin hand-held unit would be more compact and more economical than a keyboard-style Braille writer. Their first prototype demonstrated that the concept was sound, but the unit didn’t feel comfortable in the hand, so they produced a second that was superior mechanically and ergonomically. They have given their sponsor plans for a further improved model that will possess a sturdier case and modifications to keep the pins from sticking…[Officials from the project’s sponsor, the National Federation of the Blind,] say the students’ prototype can serve as a key starting point in the group’s plan to develop and distribute a low-cost, low-tech Braille writer…such a device could assist many people in this nation and around the world who cannot afford more expensive writing tools.” (Credit to MedGadget) 



July 23, 2006

Pay-4-Less?

Filed under: — mlazoff

The Centers for Medicare and Medicaid Services’ (CMS) Pay-for-Performance (P4P) incentive program is designed to improve the quality of care using (presumably) established practice guidelines. Yet two multi-center studies published in the July issue of Chest question whether it is truly the lack of quality care that accounts for the failure to meet one CMS performance standard: the Hospital Quality Alliance Pneumonia National Quality Measures PN5b, the time it takes to administer the first dose of antibiotics in hospitalized patients with pneumonia. One article, Delayed Administration of Antibiotics and Atypical Presentation in Community-Acquired Pneumonia (CAP) concluded that, “Using TFAD [the time to first antibiotic dose] as an indicator of quality of care in patients with CAP without significant additional clinical information is potentially misleading as the relationships among TFAD, comorbidities, and outcome are complex.” The second article, Antibiotic Timing and Diagnostic Uncertainty in Medicare Patients With Pneumonia: Is it Reasonable to Expect All Patients to Receive Antibiotics Within 4 Hours? found that “Many Medicare patients in whom pneumonia has been diagnosed present in an atypical manner. Delivering antibiotic treatment within 4 h[ours] for all patients would necessitate the treatment of many patients before a firm diagnosis can be made.”

The relationship between quality measures such as pay-for-performance (P4P) federal incentives, and computers, is the subject of a popular (though not universally acclaimed) commentary by Robert Wachter, MD, published in the June 21st issue of JAMA: Expected and Unanticipated Consequences of the Quality and Information Technology (IT) Revolutions. “After decades of transversing a snail-like adoption curve, computerization is also on the verge of fundamentally altering medical practice, partly because of this quality revolution.” He describes the most important outcome as “creating high-quality, more effective and safer systems for physicians as well as patients…such systems should appreciate clinical workflow, allow appropriate overrides in special circumstances, and not harm (perhaps even improve) clinicians’ efficiency.” Dr. Wachter uses several quality measures as examples to prove his point. Specifically, regarding the measure of time to administer antibiotics in pneumonia, Dr. Wachter believes that, “…quality measurement also changes the threshold for administration of the first dose of antibiotics, often persuading clinicians that the downside of delaying antibiotics for the patient who ultimately proves to have pneumonia (poor performance on the public quality report) is greater than the negative consequence for the patient with heart failure who receives antibiotics unnecessarily.” He concludes: “…until the science of guideline development and quality measurement improves, the systems must preserve physicians’ abilities to apply the art of medicine when patients do not fit the templates, such as in those patients with multisystem illness or rapidly changing disease courses.” (Inspired by the Society of General Internal Medicine (SGIM) Blog item, Another Problem With P4P written by Robert Centor, MD, SGIM President.)  



July 18, 2006

More CCHIT Chat

Filed under: — mlazoff

As anticipated in last week’s CCHIT Chat, an article in today’s Health-IT World, First Certified EHR Products Unveiled, lists the 20 products—18 currently available, 2 with pre-market certification—that “meet the first-ever criteria for functionality and interoperability of ambulatory EHRs.”  Several other products are still being tested; the names of those who pass will be made available July 31st. Certification Commission for Healthcare Information Technology (CCHIT) Chairman Mark Leavitt, MD, is quoted as not specifying the total number of applicants but said that “there were more than two dozen.” CCHIT’s site lists the certified products by company.



Or Maybe Not?

Filed under: — mlazoff

Yesterday, Health Affairs published a Market Watch article whose title says it all: It Ain’t Necessarily So: The Electronic Health Record (EHR) And The Unlikely Prospect Of Reducing Health Care Costs. Jaan Sidorov, an associate in the Department of General Internal Medicine, Geisinger Medical Center, and medical director, Care Coordination, of the Geisinger Health Plan, states that, “(a) considerable body of evidence suggests that widespread adoption of the EHR increases health care costs. Although the focus of this paper is on the limitations of the EHR in ambulatory care, ample research shows that this might likewise apply to inpatient settings.” The well referenced article reviews all the arguments in favor of EHR adoption then closes with “…Physicians must ponder the EHR’s estimated start-up and ongoing costs of $44,000 and $8,500, respectively…Patient-centeredness, shared decision making, teaming, group visits, open access, outcome responsibility, the chronic care model, and disease management are among the proposals intended to transform medical practice. The EHR’s greatest promise arguably lies in the support of these initiatives, versus the prospect of less efficiency, greater cost, inconsistent quality, and unchanged malpractice burdens resulting from a simple engraftment onto the current health care system. Accordingly, policy might be better served by caution, viewing the EHR as less of an established end and more as an inconsistent means of transformation. Finally, additional research is needed on overcoming the EHR’s limitations and dependably achieving higher quality at affordable cost.”



July 17, 2006

Medpundit pundits on

Filed under: — mlazoff

An important return: Medpundit is back online after a 2 month hiatus. One of the first (March 2002) and most respected bloggers, nom de plume Sydney Smith provides “Commentary on medical news by a practicing physician” with intelligence and humor. We’re wholly biased: we know her as Pennie Marchetti, MD, a Medical Computing Review Editorial Advisory Board member and author of two Computing Rounds, one on Relay Messaging Service (in the Nov/Dec 2005 issue) and one on HP Compaq’s TC1100 tablet PC (in the May/June 2005 issue). 



Krebs’ Fix

Filed under: — mlazoff

Last week, a trojan horse virus was discovered that takes advantage of a security flaw in email attachments using Microsoft PowerPoint—popular software among physicians for slide show presentations. Kudos to Brian Krebs’ Security Fix, a Washington Post blog that reports on such bugs and fixes. Software security giant Symantec provides instructions on how to get rid of this particular trojan horse, and recommends in general, “…not to open attachments unless [you are] expecting them. Also, do not execute software that is downloaded from the Internet unless it has been scanned for viruses. Simply visiting a compromised Web site can cause infection if certain browser vulnerabilities are not patched.”



July 15, 2006

I, Neuroprostheses

Filed under: — mlazoff

The Web focus of the July 13th issue of Nature is on neuroprostheses: electronic brain implants that translate the intention to move into actual movement of (currently) a robotic device, computer cursor, or (ultimately) paralyzed limbs. This is a wonderful all-on-one-page multimedia potpourri of link resources that include free full text access to this issue’s two published studies: one out of Brown University, on Neuronal ensemble control of prosthetic devices by a human with tetraplegia; and a second out of Stanford University, on A high-performance brain-computer interface involving rhesus monkeys. The video streaming and experimental footage is fun viewing of this technology at its infancy. Alas, the news features and Archives of past Nature articles on the topic are not freely available to non-subscribers. A sobering editorial closes with a reference to the Six Million Dollar Man of 1970s television: “The idea of giving people superhuman powers greatly appeals to the popular imagination. But in the real world, using neuroprosthetics to give patients control over all the less glamorous things we take for granted will be more important.”



July 10, 2006

CCHIT Chat

Filed under: — mlazoff

The first of the Certification Commission for Healthcare Information Technology (CCHIT)-certified electronic health records (EHRs), this one for ambulatory EHRs, will be posted any day now. CCHIT was formed two years ago this month as a voluntary, private sector organization to develop and evaluate certification criteria and the inspection process for all commercial EHRs. Towards this end, CCHIT was awarded a three year, $2.7 million dollar Health and Human Services (HHS) contract last September. CCHIT’s Chairman, Mark Leavitt, MD, PhD, is unrelated to HHS Secretary Mike Leavitt, MD, who also chairs the American Health Information Community (AHIC) whose advisory board recommended last May that HHS accept CCHIT’s new certification guidelines. An article published in the May 25th issue of Health-IT World.com, CCHIT Meeting Draws Ire from Vendors, Ideas from Leaders, describes the financial and business concerns of small vendors towards what they regard as an all-but-mandatory certification program. According to the article, “[Dr. Mark] Leavitt tried to assuage concerns by saying that certification will help business. ‘If you don’t see an acceleration in the [EHR] market, then we’ve failed,’ he said.” (Updated July 18, 2006 by mlazoff)



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